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Brain abscess from chronic odontogenic cause: report of case
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Brain abscess from chronic odontogenic cause: report of case C h risto p h er J. S aal, D D S J o h n C. M ason , D D S Shu L. C heuk, DDS M ich a el K. H ill, M D
A report o f case o f a brain abscess p ro b a b ly caused by an o d on togen ic abscess via h em atogenou s spread is presented. Thorough m edical w orkup showed no other sources of infection. A com m on p a th o g en was iso la ted between the two abscesses. The im por tance of dental care in the hospital is emphasized.
ental infections are often over lo o k e d as a ca u se of b r a in ab sce ss.1”4 M ore often a b ra in abscess m ay d ev e lo p as a se q u e la e to cavernous sinus throm bosis precipitated by an o dontogenic infection.5 In a review of 28 fatal cases of central nervous system infections th o u g h t to be initiated by tooth e x tr a c tio n , H a y m a k e r6 a c c o u n te d for eight developing brain abscesses. In an analysis of 212 b rain abscesses by Courv ille ,7 te e th w ere im p lic a te d as th e prim ary source in one instance. H o llin an d o th e rs ,5 in a study e n c o m p a ssin g 25 years, re p o rte d tw o b ra in abscesses of d e n ta l o r ig in fro m 114 cases of in tra c ra n ia l su p p u ra tio n .5 In a 15-year review of the m ortality of patients w ith b r a in abscesses, A ld erso n a n d o th e rs 8 r e p o rte d 90 b r a in abscesses, of w h ic h two were believed to be of dental o rig in .8 T h e r e p o r t of case p re s e n te d h ere
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d escrib es a b r a in abscess p re c ip ita te d by a chronic periapical infection.
Report of case
A 51-year-old b lack m ale was b ro u g h t to Earl K. L o n g H ospital in Baton Rouge, L A , by th e lo c a l em erg en c y m e d ica l service because of seizure activity. T h e to n ic /c lo n ic seizure lasted approxim ately 5 m inutes an d was follow ed by a sim ilar seizure at the h o sp ital d u rin g the initial physical exam ination. T h e m edical history included a report of a sim ilar seizure approxim ately 3 years before this episode; however, no medical
F ig
1 ■ C T scan sh o w s a paraven tricu lar
frontoparietal lesion.
tr e a tm e n t w as s o u g h t a t th a t tim e. S ignificant m edical history also included tr e a tm e n t fo r h y p e r te n s io n , c ig a r e tte sm o k in g of one pack daily for 20 years, an d eth an o l abuse. R esults of the in itia l physical ex am in atio n were un rem ark ab le w ith no focal neurological findings; the p a tie n t’s vital sig n s w ere sta b le a n d h e w as n o ta b ly a fe b rile . L a b o r a to ry d a ta in c lu d e d a com plete blood cell co u n t w hich show ed a n elev ated w h ite b lo o d cell c o u n t of 12.1 x 103. U rinalysis, serum electrolytes, glucose, blood urea nitrogen, an d creat in in e were w ith in n o rm al lim its. A chest ra d io g ra p h show ed h y p e rin fla te d lu n g fields w ith diffuse scarring in the rig h t u p p er lobe and m oderate left ventricular e n la rg e m e n t. An e le c tro c a rd io g ra m sh o w e d n o n s p e c if ic in tr a v e n tr ic u la r co n d u c tio n delay an d m in im a l voltage criteria for left v entricular hypertrophy. T h e p a t ie n t w as a d m itte d to th e m e d ic in e serv ice a t th e h o s p ita l w ith the clinical w o rking diagnosis of a seizure d iso rd er of u n k n o w n o rig in . T h e p la n was to rule o u t m eningitis, tuberculosis, o r fu n g al o r b ac te ria l in fec tio n versus a neoplastic process. T h e in itial ex am in atio n also included a C T scan of th e h e a d a n d th e chest. T h e C T scan of the head show ed a left fro n to p arietal, large low -density lesion, w h ic h e n h a n c e d w ith c o n tra st. T h e re was no evidence of a m id lin e shift. T h e JADA, Vol. 117, September 1988 ■ 453
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C T scan of th e ch est sh o w ed ch anges consistent w ith chronic obstructive p u l m onary disease, as w ell as enlargem ent of the m ediastinal lym ph nodes w ithin the su p erio r m ediastinum . T h e clinical im p ressio n at th a t tim e was carcinom a of the lu ng, w ith the prim ary lesion in on e of the u p p e r lu n g regions and the b r a in le s io n b e in g a m e ta s ta tic site. However, the possibility of a brain abscess could n ot com pletely be ruled out. F u rth er evaluation included bronchos copy, b ronchial biopsy, and m ediastinal ly m p h n o d e b io p sy . B ro n c h o sc o p y show ed an area of extrinsic com pression in the left low er lobe w ith o u t evidence of in tr in s ic m ass. B ro n ch ial w ash in g s of the area were subsequently negative. H is to lo g ic a l re p o rts of th e b r o n c h ia l biopsy specim en show ed focal squam ous m etap lasia w ith chro n ic inflam m atio n . M ediastinal lym ph nodes were w ithout tum or; however, anthracosis was noted. T h e p atien t was hospitalized w ith the m edicine service for 15 days, d u rin g w hich tim e h is c o n d itio n d e te r io r a te d . T h e p a tie n t’s m e n ta l sta tu s p rogressively d ec lin e d a n d a rig h t-sid e d h e m ip le g ia d ev e lo p e d . A fter staff c o n s u lta tio n , it was d eterm ined th a t the p a tie n t w ould benefit from a neurosurgical consultation. As no neurosurgical service was available at th is h o sp ital, the p a tie n t w as tran s ferred to C harity H o spital, New O rleans. T h e p h y sic a l e x a m in a tio n d o n e by the n eurosurgical service showed: rig h t sided hem iplegia w ith right-sided Babinsk i’s sign an d clonus, and an expressive/ receptive aph asia. D eep tendon reflexes w ere in ta c t b ila te r a lly . S om e u p p e r re s p ir a to ry r h o n c h u s w as n o te d . S ig nifican t laboratory values included: w hite b lood cell co u n t 18.1 (4.0-11) an d sodium 127 (135-142). A second C T scan of the head was done (Fig 1). T h e tom ograph show ed a p ara v e n tric u la r f ro n to p a r ie ta l le sio n w ith a central p o rtio n of decreased attenuation surrounded by a uniform border, w hich was increased w ith contrast. T h e lesion w as su rro u n d e d by in te r s titia l edem a, w ith m id lin e sh ift to the rig h t. T h ese ch aracteristics are com m on find in g s of a b ra in abscess. H ow ever, a m etastatic b ra in lesion co u ld not be ru led o u t as the fro n ta l an d p arietal lobes are com m only involved in m etastatic diseases. Im p ression on adm ission to the n eu ro su rg ical service included a m etastatic b ra in lesio n versus b ra in abscess. T h e p atien t was taken to em ergency surgery w here the d iag n o sis of a b ra in abscess was confirm ed. T h e abscess was evacuated 454 ■ JADA, Vol. 117, September 1988
an d cultures were subm itted. T h e patien t to le ra te d th e p ro c e d u re w ith o u t c o m p lic a tio n . P o sto p e ra tiv e ly , th e p a tie n t was giv en d e x a m e th a so n e (D ecadron), phenytoin, am p icillin , chloram phenicol, an d m ezlocillin. In an a tte m p t to find a possib le source of th e b ra in abscess, blood, sputum , an d u rin e cultures were subm itted to the laboratory. All results were negative. O n p o stop erativ e day two, the infec tious disease d ep a rtm en t was consulted as the o rig in of the b rain abscess rem ained u n k n o w n . T h is d e p a r tm e n t re c o m mended: start intravenous metronidazole, 1,100-mg lo ad in g dose follow ed by 500 m g every 6 hours; d iscontinue mezlocillin; c o n tin u e in tra v e n o u s c h lo ra m p h e n ic o l 1 g every 6 hours; follow -up w ith 6 weeks of a n tib io tic th e ra p y ; a n d c o n s u lt the dental service for possible o d o n to g en ic origin. O n p o sto p e ra tiv e day six, a c o n s u l tation was obtained from the departm ent of g e n e ra l d e n tis tr y . H e a d a n d neck exam ination was unrem arkable; no facial asy m m e try o r ly m p h a d e n o p a th y w ere p rese n t. A n o ra l e x a m in a tio n show ed th e b uccal m u co sa, to n g u e , a n d flo o r of the m o u th w ith in norm al lim its. T h e gingiva appeared coral p in k and fibrotic w ith a loss o f s tip p lin g . P e r io d o n ta l pocketing ranged from 3 to 9 mm. T h e m a x illa ry le ft la te r a l in c is o r sh o w ed p ocketing depths of 8 mm distally and 6 m m m esially. T h e re w ere no d en tal restorations or clinical caries evident.
P anoram ic an d periapical radiographs show ed generalized bone loss of ap p ro x im a te ly 40%. A la rg e p e r ia p ic a l rad io lucent area su rro u n d in g the apexes of th e m a x illa ry le ft c e n tra l a n d la te ra l in c is o rs w as n o te d . T h e c a n a l of th e central incisor was calcified. A m axillary occlusal rad io g rap h show ed a u n ilo cu lar ra d io lu c e n t lesio n m easu rin g 1.5 x 1.3 cm (Fig 2). T h e left lateral incisor p u lp tested n o n v ita l. D iffe re n tia l d ia g n o sis included: p e ria p ic a l abscess, p eriap ical g ra n u lo m a , ra d ic u la r cyst, an d cen tral hem angiom a. T o ru le o u t the possibility of a vascular lesion, the area was aspirated w ith a n 1 8 -g au g e n eed le. A p u r u le n t exudate was o btained an d subm itted for a n a e ro b ic a n d ae ro b ic c u ltu re as w ell as gram stain. G iven the physical co n d itio n an d the clinical an d rad io g rap h ic findings, the lateral incisor was removed a n d th e le s io n c u re tte d th r o u g h th e extraction site. C u ltu re s o f th e b r a in ab scess a n d o d o n to g e n ic abscess, a n d g ram sta in s of each, were com pared. G ram stain of th e b ra in abscess show ed w h ite b lo o d c e lls is o la te d g r a m -p o s itiv e co cci in c h ain s an d clusters. G ram stain of the o d o n to g e n ic abscess show ed gram p o s itiv e co cci in c h a in s . Five o rg a n ism s g rew o u t of th e c u ltu r e o f th e b r a in abscess: S tr e p to c o c c u s a n g in o s is -c o n stellatus, Bacteroides oralis, Peptostreptococcus micros, Bacteroides ureolyticus, a n d V eillonella parvula. T w o organism s grew from the cu ltu re of the dental abscess
CLINICAL
a lth o u g h th e p a tie n t h a d rec eiv e d a sp e c tru m a n tib io tic re g im e n (6 days). T h ese o rg an ism s in c lu d e d Peptostreptococcus sp a n d E nterobacteriaceae
cloacae. T h e p a tie n t h a d a n u n c o m p lic a te d p o s to p e ra tiv e co u rse . By th e tim e of discharge, the leukocytosis, expressive/ receptive aphasia, an d right-sided hem i plegia were resolving, as was the odon to g en ic abscess. C u rren tly , the p a tie n t is b ein g follow ed in the n eu ro su rg ery and d en tal clinics. F igure 3 show s the sam e area 6 m o n th s after e x tra c tio n s. T h e m a x illa ry c e n tr a l in c is o r w as e x tra c te d 4 m o n th s la te r b ec au se of c o n firm e d p e rio d o n tic /e n d o d o n tic i n volvement. Discussion
T h e case re p o rte d h ere re p re se n ts an exam ple of a brain abscess precipitated by a c h r o n ic o d o n to g e n ic abscess. A review of the literature shows the m ajority of in tr a c r a n ia l se p sis o f o d o n to g e n ic o rig in is a sequel to acute rath e r th an c h ro n ic d e n ta l in f e c tio n .5 S p ro tt a n d others9 described two patients w ith brain abscess in w hom the prim ary source, of the infection was believed to be asym p tom atic teeth. A nother case is described in the literature in w hich a brain abscess w as in itia te d a n d m a in ta in e d by periodontally involved teeth.10 T h e m ethod of spread to involve the in tracran ial cavity can occur by way of hem atogenous spread or th ro u g h direct e x te n s io n .11-13 B ra in abscesses w ill develop frequently as a result of m etastatic sp re a d of in f e c tio n fro m a c h r o n ic s u p p u r a ti o n .14 H e m a to g e n o u s sp re a d of infection to the brain from a distant focus has been show n to locate prim arily a lo n g th e d is tr ib u tio n o f th e m id d le cerebral artery (for ex am p le, p o ste rio r frontal or parietal lobes) sim ilar to the case reported in this p ap e r.15 T h e p atient may initially have sym p tom s of m a la ise , h e a d a c h e , d ecreased appetite, chills, fever, an d emesis. W ith tim e, this m ay progress to convulsions and focal neurological deficits including a p h a s ia , h e m ip a re sis, a n d p a th o g e n ic reflexes. However, early sym ptom s may n o t be in fectious a n d m ay consist p r i
m arily of headache a n d focal neurological signs w ith o u t fever.5,14 O f significance in the case presented here are the com m on organism s between the o d o n to g e n ic a n d the b ra in abscess despite 6 days of an tib io tic therapy before c u ltu r e o f th e o d o n to g e n ic abscess. Peptostreptococcus sp were rep o rted in bo th isolate cultures. T h e m icrobiologic c h a ra c te ristic s of d e n ta l abscesses are d iv erse a n d ca n vary. A c c o rd in g to S abiston an d o th e rs16 in a series of 65 d e n ta l abscesses, seven c u ltu r e s w ere n egative a n d 58 w ere p o sitiv e for one to 12 species. O b lig a te a n a e ro b e s accounted for 65% of the species isolated. T hey also concluded th at oral abscesses consisted of norm al oral flora, and that no single g ro u p or co m bination of species could be identified as essential.16 A single case of b rain abscess from odontogenic origin resulted in d eath .17 T h e m icrob io lo g y of b ra in abscesses is as d iverse as d e n ta l abscesses. In a study of 60 patien ts w ith b rain abscess at Mayo C lin ic,15 gram negative aerobic a n d anaerobic org an ism s were isolated from patients w ith a variety of etiologic foci of in f e c tio n . A sp e c ific fo cu s of in fe c tio n w ill n o t u s u a lly d ic ta te the m ic ro b io lo g ic o rig in of th e b r a in ab scess. In 32% of the p a tie n ts in c lu d e d in this study, m ore th an one organism was isolated from surgically excised brain abscesses. T h e in itial antibiotic regim en m ust therefore cover a b ro ad spectrum of p a th o g e n s a lo n g w ith early n e u ro surgical intervention.
Summary
A case of a chronic odontogenic abscess th a t p ro b ab ly p re c ip ita te d a fro n to p a rie ta l b r a in abscess by h e m a to g e n o u s spread has been presented. A th o ro u g h e x a m in a tio n of the p a tie n t show ed no o th e r source o f in fe c tio n . P eptostrep tococcus sp was fo u n d as the com m on p a th o g e n d e s p ite 6 days o f b ro ad spectrum a n tib io tic therapy. T h is case em phasizes the im p o rta n t role of dentistry in m e d ic a l d ia g n o s is a n d tre a tm e n t im plem ented in the ho sp ital setting.
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REPORTS
Dr. Saal is a second-year resident, and Dr. Mason is an a tten d in g d entist, N orthw estern U niversity M em orial H o s p ita l, C h ic a g o , an d is in private practice, St. Charles, IL. Dr. C heuk is professor, departm ent of general dentistry, L o u isian a State U n iversity M edical C enter, S ch o o l of D entistry, 1100 F lorid a Ave, N ew O rleans, LA 70119-2799. Dr. H ill is a fellow, department of medicine, Charity H o sp ita l o f L o u isia n a at N ew O rleans. Address requests for reprints to Dr. Cheuk. 1. G otein er, D.; S o n is, S .T .; and Fasciano, R. C avern ous s in u s th ro m b o sis and brain abscess initiated and m aintained by periodontally involved teeth. J Oral Med 37(3):80-83, 1982. 2. Kemper, J.W., and Aseltine, L.F. Intracranial lesions resulting from dental infection. Am J Orthod Oral Surg 30:701-703, 1944. 3. M arlette, R .H .; Gerhard, R .C .; and C onley, J. Brain abscess of dental origin: report o f case. J Oral Surg 28:134-137, 1970. 4. Baddour, H.M.; Durst, N.L.; and T ilson , H.B. Frontal lobe abscess o f dental o rig in . Oral Surg Oral Med Oral Path 47(4):303-306, 1979. 5. H o llin , S.A.; H ayash i, H .; and G ross, S.W. Intracranial abscesses of odon togenic origin. Oral Surg Oral Med Oral Pathol 23(3):277-293, 1967. 6. Haymaker, C.W. Fatal infections of the central nervous system and m eninges after tooth extraction: with an analysis of twenty-eight cases. Am J Orthod Oral Surg 31:117-188, 1945. 7. Courville, C.B. Pathology of the nervous system, ed 2. M ountain View, CA, Pacific Press Publishing Assoc, 1945, p 182. 8. A lderson, D ., and others. Fifteen-year review o f the m orta lity o f brain abscess. N eurosurgery 8(1): 1-6, 1981. 9. S p rott, M .S., an d oth ers. S u b d u ral abscess secondary to covert d en tal sep sis. Postgrad Med J 57:649-651, 1981. 10. G allagher, D.M .; Erickson, K.; and H o llin , S.A . F atal brain abscess f o llo w in g p e r io d o n ta l therapy: a case report. Mt Sinai J Med 48(2): 158160, 1981. 11. Loeser, E., and Scheinberg, L. Brain abscesses: a review of ninety-nine cases. N eurology 7(9):599609, 1957. 12. Brook, I., and Friedm an, E.M. Intracranial c o m p lica tio n s o f sin u sitis in children: a seq uela of periapical abscess. A nn O tol R h in ol L aryngol 91:41-43, 1982. 13. Churton, M.C., and Greer, N .D . Intracranial abscess secondary to dental in fection . NZ D ent J 76:58-60, 1980. 14. Brewer, N.S.; MacCarty, C.S.; and W ellman, W.E. Brain abscess: a review of recent experience. A nn Intern Med 82(4):57I-576, 1975. 15. M andell, G.L.; D ouglas, R.G.; and Bennett, J.E. P rin cip les and practice of infectious disease, ed 2. N ew York, John W iley and Sons, Inc, 1979, 1985, pp 585-591. 16. S a b isto n , C .B ., Jr.; G rigsb y, W .R .; and Segerstrom, N. Bacterial study of pyogenic infections of dental origin. Oral Surg Oral Med Oral Pathol 41(4):430-435, 1976. 17. Aldous, J.A.; Pow ell, G.L.; and Stenssas, S.S. Brain abscess of odontogenic origin: report of case. JADA 115(6):861-863, 1987.
Saal-Others : BRAIN ABSCESS FROM O DO NTOGENIC CAUSE ■ 455
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Brain abscess from chronic odontogenic cause: report of case C h risto p h er J. S aal, D D S J o h n C. M ason , D D S Shu L. C heuk, DDS M ich a el K. H ill, M D
A report o f case o f a brain abscess p ro b a b ly caused by an o d on togen ic abscess via h em atogenou s spread is presented. Thorough m edical w orkup showed no other sources of infection. A com m on p a th o g en was iso la ted between the two abscesses. The im por tance of dental care in the hospital is emphasized.
ental infections are often over lo o k e d as a ca u se of b r a in ab sce ss.1”4 M ore often a b ra in abscess m ay d ev e lo p as a se q u e la e to cavernous sinus throm bosis precipitated by an o dontogenic infection.5 In a review of 28 fatal cases of central nervous system infections th o u g h t to be initiated by tooth e x tr a c tio n , H a y m a k e r6 a c c o u n te d for eight developing brain abscesses. In an analysis of 212 b rain abscesses by Courv ille ,7 te e th w ere im p lic a te d as th e prim ary source in one instance. H o llin an d o th e rs ,5 in a study e n c o m p a ssin g 25 years, re p o rte d tw o b ra in abscesses of d e n ta l o r ig in fro m 114 cases of in tra c ra n ia l su p p u ra tio n .5 In a 15-year review of the m ortality of patients w ith b r a in abscesses, A ld erso n a n d o th e rs 8 r e p o rte d 90 b r a in abscesses, of w h ic h two were believed to be of dental o rig in .8 T h e r e p o r t of case p re s e n te d h ere
D
d escrib es a b r a in abscess p re c ip ita te d by a chronic periapical infection.
Report of case
A 51-year-old b lack m ale was b ro u g h t to Earl K. L o n g H ospital in Baton Rouge, L A , by th e lo c a l em erg en c y m e d ica l service because of seizure activity. T h e to n ic /c lo n ic seizure lasted approxim ately 5 m inutes an d was follow ed by a sim ilar seizure at the h o sp ital d u rin g the initial physical exam ination. T h e m edical history included a report of a sim ilar seizure approxim ately 3 years before this episode; however, no medical
F ig
1 ■ C T scan sh o w s a paraven tricu lar
frontoparietal lesion.
tr e a tm e n t w as s o u g h t a t th a t tim e. S ignificant m edical history also included tr e a tm e n t fo r h y p e r te n s io n , c ig a r e tte sm o k in g of one pack daily for 20 years, an d eth an o l abuse. R esults of the in itia l physical ex am in atio n were un rem ark ab le w ith no focal neurological findings; the p a tie n t’s vital sig n s w ere sta b le a n d h e w as n o ta b ly a fe b rile . L a b o r a to ry d a ta in c lu d e d a com plete blood cell co u n t w hich show ed a n elev ated w h ite b lo o d cell c o u n t of 12.1 x 103. U rinalysis, serum electrolytes, glucose, blood urea nitrogen, an d creat in in e were w ith in n o rm al lim its. A chest ra d io g ra p h show ed h y p e rin fla te d lu n g fields w ith diffuse scarring in the rig h t u p p er lobe and m oderate left ventricular e n la rg e m e n t. An e le c tro c a rd io g ra m sh o w e d n o n s p e c if ic in tr a v e n tr ic u la r co n d u c tio n delay an d m in im a l voltage criteria for left v entricular hypertrophy. T h e p a t ie n t w as a d m itte d to th e m e d ic in e serv ice a t th e h o s p ita l w ith the clinical w o rking diagnosis of a seizure d iso rd er of u n k n o w n o rig in . T h e p la n was to rule o u t m eningitis, tuberculosis, o r fu n g al o r b ac te ria l in fec tio n versus a neoplastic process. T h e in itial ex am in atio n also included a C T scan of th e h e a d a n d th e chest. T h e C T scan of the head show ed a left fro n to p arietal, large low -density lesion, w h ic h e n h a n c e d w ith c o n tra st. T h e re was no evidence of a m id lin e shift. T h e JADA, Vol. 117, September 1988 ■ 453
C L I N I C A L
R E P O R T S
C T scan of th e ch est sh o w ed ch anges consistent w ith chronic obstructive p u l m onary disease, as w ell as enlargem ent of the m ediastinal lym ph nodes w ithin the su p erio r m ediastinum . T h e clinical im p ressio n at th a t tim e was carcinom a of the lu ng, w ith the prim ary lesion in on e of the u p p e r lu n g regions and the b r a in le s io n b e in g a m e ta s ta tic site. However, the possibility of a brain abscess could n ot com pletely be ruled out. F u rth er evaluation included bronchos copy, b ronchial biopsy, and m ediastinal ly m p h n o d e b io p sy . B ro n c h o sc o p y show ed an area of extrinsic com pression in the left low er lobe w ith o u t evidence of in tr in s ic m ass. B ro n ch ial w ash in g s of the area were subsequently negative. H is to lo g ic a l re p o rts of th e b r o n c h ia l biopsy specim en show ed focal squam ous m etap lasia w ith chro n ic inflam m atio n . M ediastinal lym ph nodes were w ithout tum or; however, anthracosis was noted. T h e p atien t was hospitalized w ith the m edicine service for 15 days, d u rin g w hich tim e h is c o n d itio n d e te r io r a te d . T h e p a tie n t’s m e n ta l sta tu s p rogressively d ec lin e d a n d a rig h t-sid e d h e m ip le g ia d ev e lo p e d . A fter staff c o n s u lta tio n , it was d eterm ined th a t the p a tie n t w ould benefit from a neurosurgical consultation. As no neurosurgical service was available at th is h o sp ital, the p a tie n t w as tran s ferred to C harity H o spital, New O rleans. T h e p h y sic a l e x a m in a tio n d o n e by the n eurosurgical service showed: rig h t sided hem iplegia w ith right-sided Babinsk i’s sign an d clonus, and an expressive/ receptive aph asia. D eep tendon reflexes w ere in ta c t b ila te r a lly . S om e u p p e r re s p ir a to ry r h o n c h u s w as n o te d . S ig nifican t laboratory values included: w hite b lood cell co u n t 18.1 (4.0-11) an d sodium 127 (135-142). A second C T scan of the head was done (Fig 1). T h e tom ograph show ed a p ara v e n tric u la r f ro n to p a r ie ta l le sio n w ith a central p o rtio n of decreased attenuation surrounded by a uniform border, w hich was increased w ith contrast. T h e lesion w as su rro u n d e d by in te r s titia l edem a, w ith m id lin e sh ift to the rig h t. T h ese ch aracteristics are com m on find in g s of a b ra in abscess. H ow ever, a m etastatic b ra in lesion co u ld not be ru led o u t as the fro n ta l an d p arietal lobes are com m only involved in m etastatic diseases. Im p ression on adm ission to the n eu ro su rg ical service included a m etastatic b ra in lesio n versus b ra in abscess. T h e p atien t was taken to em ergency surgery w here the d iag n o sis of a b ra in abscess was confirm ed. T h e abscess was evacuated 454 ■ JADA, Vol. 117, September 1988
an d cultures were subm itted. T h e patien t to le ra te d th e p ro c e d u re w ith o u t c o m p lic a tio n . P o sto p e ra tiv e ly , th e p a tie n t was giv en d e x a m e th a so n e (D ecadron), phenytoin, am p icillin , chloram phenicol, an d m ezlocillin. In an a tte m p t to find a possib le source of th e b ra in abscess, blood, sputum , an d u rin e cultures were subm itted to the laboratory. All results were negative. O n p o stop erativ e day two, the infec tious disease d ep a rtm en t was consulted as the o rig in of the b rain abscess rem ained u n k n o w n . T h is d e p a r tm e n t re c o m mended: start intravenous metronidazole, 1,100-mg lo ad in g dose follow ed by 500 m g every 6 hours; d iscontinue mezlocillin; c o n tin u e in tra v e n o u s c h lo ra m p h e n ic o l 1 g every 6 hours; follow -up w ith 6 weeks of a n tib io tic th e ra p y ; a n d c o n s u lt the dental service for possible o d o n to g en ic origin. O n p o sto p e ra tiv e day six, a c o n s u l tation was obtained from the departm ent of g e n e ra l d e n tis tr y . H e a d a n d neck exam ination was unrem arkable; no facial asy m m e try o r ly m p h a d e n o p a th y w ere p rese n t. A n o ra l e x a m in a tio n show ed th e b uccal m u co sa, to n g u e , a n d flo o r of the m o u th w ith in norm al lim its. T h e gingiva appeared coral p in k and fibrotic w ith a loss o f s tip p lin g . P e r io d o n ta l pocketing ranged from 3 to 9 mm. T h e m a x illa ry le ft la te r a l in c is o r sh o w ed p ocketing depths of 8 mm distally and 6 m m m esially. T h e re w ere no d en tal restorations or clinical caries evident.
P anoram ic an d periapical radiographs show ed generalized bone loss of ap p ro x im a te ly 40%. A la rg e p e r ia p ic a l rad io lucent area su rro u n d in g the apexes of th e m a x illa ry le ft c e n tra l a n d la te ra l in c is o rs w as n o te d . T h e c a n a l of th e central incisor was calcified. A m axillary occlusal rad io g rap h show ed a u n ilo cu lar ra d io lu c e n t lesio n m easu rin g 1.5 x 1.3 cm (Fig 2). T h e left lateral incisor p u lp tested n o n v ita l. D iffe re n tia l d ia g n o sis included: p e ria p ic a l abscess, p eriap ical g ra n u lo m a , ra d ic u la r cyst, an d cen tral hem angiom a. T o ru le o u t the possibility of a vascular lesion, the area was aspirated w ith a n 1 8 -g au g e n eed le. A p u r u le n t exudate was o btained an d subm itted for a n a e ro b ic a n d ae ro b ic c u ltu re as w ell as gram stain. G iven the physical co n d itio n an d the clinical an d rad io g rap h ic findings, the lateral incisor was removed a n d th e le s io n c u re tte d th r o u g h th e extraction site. C u ltu re s o f th e b r a in ab scess a n d o d o n to g e n ic abscess, a n d g ram sta in s of each, were com pared. G ram stain of th e b ra in abscess show ed w h ite b lo o d c e lls is o la te d g r a m -p o s itiv e co cci in c h ain s an d clusters. G ram stain of the o d o n to g e n ic abscess show ed gram p o s itiv e co cci in c h a in s . Five o rg a n ism s g rew o u t of th e c u ltu r e o f th e b r a in abscess: S tr e p to c o c c u s a n g in o s is -c o n stellatus, Bacteroides oralis, Peptostreptococcus micros, Bacteroides ureolyticus, a n d V eillonella parvula. T w o organism s grew from the cu ltu re of the dental abscess
CLINICAL
a lth o u g h th e p a tie n t h a d rec eiv e d a sp e c tru m a n tib io tic re g im e n (6 days). T h ese o rg an ism s in c lu d e d Peptostreptococcus sp a n d E nterobacteriaceae
cloacae. T h e p a tie n t h a d a n u n c o m p lic a te d p o s to p e ra tiv e co u rse . By th e tim e of discharge, the leukocytosis, expressive/ receptive aphasia, an d right-sided hem i plegia were resolving, as was the odon to g en ic abscess. C u rren tly , the p a tie n t is b ein g follow ed in the n eu ro su rg ery and d en tal clinics. F igure 3 show s the sam e area 6 m o n th s after e x tra c tio n s. T h e m a x illa ry c e n tr a l in c is o r w as e x tra c te d 4 m o n th s la te r b ec au se of c o n firm e d p e rio d o n tic /e n d o d o n tic i n volvement. Discussion
T h e case re p o rte d h ere re p re se n ts an exam ple of a brain abscess precipitated by a c h r o n ic o d o n to g e n ic abscess. A review of the literature shows the m ajority of in tr a c r a n ia l se p sis o f o d o n to g e n ic o rig in is a sequel to acute rath e r th an c h ro n ic d e n ta l in f e c tio n .5 S p ro tt a n d others9 described two patients w ith brain abscess in w hom the prim ary source, of the infection was believed to be asym p tom atic teeth. A nother case is described in the literature in w hich a brain abscess w as in itia te d a n d m a in ta in e d by periodontally involved teeth.10 T h e m ethod of spread to involve the in tracran ial cavity can occur by way of hem atogenous spread or th ro u g h direct e x te n s io n .11-13 B ra in abscesses w ill develop frequently as a result of m etastatic sp re a d of in f e c tio n fro m a c h r o n ic s u p p u r a ti o n .14 H e m a to g e n o u s sp re a d of infection to the brain from a distant focus has been show n to locate prim arily a lo n g th e d is tr ib u tio n o f th e m id d le cerebral artery (for ex am p le, p o ste rio r frontal or parietal lobes) sim ilar to the case reported in this p ap e r.15 T h e p atient may initially have sym p tom s of m a la ise , h e a d a c h e , d ecreased appetite, chills, fever, an d emesis. W ith tim e, this m ay progress to convulsions and focal neurological deficits including a p h a s ia , h e m ip a re sis, a n d p a th o g e n ic reflexes. However, early sym ptom s may n o t be in fectious a n d m ay consist p r i
m arily of headache a n d focal neurological signs w ith o u t fever.5,14 O f significance in the case presented here are the com m on organism s between the o d o n to g e n ic a n d the b ra in abscess despite 6 days of an tib io tic therapy before c u ltu r e o f th e o d o n to g e n ic abscess. Peptostreptococcus sp were rep o rted in bo th isolate cultures. T h e m icrobiologic c h a ra c te ristic s of d e n ta l abscesses are d iv erse a n d ca n vary. A c c o rd in g to S abiston an d o th e rs16 in a series of 65 d e n ta l abscesses, seven c u ltu r e s w ere n egative a n d 58 w ere p o sitiv e for one to 12 species. O b lig a te a n a e ro b e s accounted for 65% of the species isolated. T hey also concluded th at oral abscesses consisted of norm al oral flora, and that no single g ro u p or co m bination of species could be identified as essential.16 A single case of b rain abscess from odontogenic origin resulted in d eath .17 T h e m icrob io lo g y of b ra in abscesses is as d iverse as d e n ta l abscesses. In a study of 60 patien ts w ith b rain abscess at Mayo C lin ic,15 gram negative aerobic a n d anaerobic org an ism s were isolated from patients w ith a variety of etiologic foci of in f e c tio n . A sp e c ific fo cu s of in fe c tio n w ill n o t u s u a lly d ic ta te the m ic ro b io lo g ic o rig in of th e b r a in ab scess. In 32% of the p a tie n ts in c lu d e d in this study, m ore th an one organism was isolated from surgically excised brain abscesses. T h e in itial antibiotic regim en m ust therefore cover a b ro ad spectrum of p a th o g e n s a lo n g w ith early n e u ro surgical intervention.
Summary
A case of a chronic odontogenic abscess th a t p ro b ab ly p re c ip ita te d a fro n to p a rie ta l b r a in abscess by h e m a to g e n o u s spread has been presented. A th o ro u g h e x a m in a tio n of the p a tie n t show ed no o th e r source o f in fe c tio n . P eptostrep tococcus sp was fo u n d as the com m on p a th o g e n d e s p ite 6 days o f b ro ad spectrum a n tib io tic therapy. T h is case em phasizes the im p o rta n t role of dentistry in m e d ic a l d ia g n o s is a n d tre a tm e n t im plem ented in the ho sp ital setting.
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REPORTS
Dr. Saal is a second-year resident, and Dr. Mason is an a tten d in g d entist, N orthw estern U niversity M em orial H o s p ita l, C h ic a g o , an d is in private practice, St. Charles, IL. Dr. C heuk is professor, departm ent of general dentistry, L o u isian a State U n iversity M edical C enter, S ch o o l of D entistry, 1100 F lorid a Ave, N ew O rleans, LA 70119-2799. Dr. H ill is a fellow, department of medicine, Charity H o sp ita l o f L o u isia n a at N ew O rleans. Address requests for reprints to Dr. Cheuk. 1. G otein er, D.; S o n is, S .T .; and Fasciano, R. C avern ous s in u s th ro m b o sis and brain abscess initiated and m aintained by periodontally involved teeth. J Oral Med 37(3):80-83, 1982. 2. Kemper, J.W., and Aseltine, L.F. Intracranial lesions resulting from dental infection. Am J Orthod Oral Surg 30:701-703, 1944. 3. M arlette, R .H .; Gerhard, R .C .; and C onley, J. Brain abscess of dental origin: report o f case. J Oral Surg 28:134-137, 1970. 4. Baddour, H.M.; Durst, N.L.; and T ilson , H.B. Frontal lobe abscess o f dental o rig in . Oral Surg Oral Med Oral Path 47(4):303-306, 1979. 5. H o llin , S.A.; H ayash i, H .; and G ross, S.W. Intracranial abscesses of odon togenic origin. Oral Surg Oral Med Oral Pathol 23(3):277-293, 1967. 6. Haymaker, C.W. Fatal infections of the central nervous system and m eninges after tooth extraction: with an analysis of twenty-eight cases. Am J Orthod Oral Surg 31:117-188, 1945. 7. Courville, C.B. Pathology of the nervous system, ed 2. M ountain View, CA, Pacific Press Publishing Assoc, 1945, p 182. 8. A lderson, D ., and others. Fifteen-year review o f the m orta lity o f brain abscess. N eurosurgery 8(1): 1-6, 1981. 9. S p rott, M .S., an d oth ers. S u b d u ral abscess secondary to covert d en tal sep sis. Postgrad Med J 57:649-651, 1981. 10. G allagher, D.M .; Erickson, K.; and H o llin , S.A . F atal brain abscess f o llo w in g p e r io d o n ta l therapy: a case report. Mt Sinai J Med 48(2): 158160, 1981. 11. Loeser, E., and Scheinberg, L. Brain abscesses: a review of ninety-nine cases. N eurology 7(9):599609, 1957. 12. Brook, I., and Friedm an, E.M. Intracranial c o m p lica tio n s o f sin u sitis in children: a seq uela of periapical abscess. A nn O tol R h in ol L aryngol 91:41-43, 1982. 13. Churton, M.C., and Greer, N .D . Intracranial abscess secondary to dental in fection . NZ D ent J 76:58-60, 1980. 14. Brewer, N.S.; MacCarty, C.S.; and W ellman, W.E. Brain abscess: a review of recent experience. A nn Intern Med 82(4):57I-576, 1975. 15. M andell, G.L.; D ouglas, R.G.; and Bennett, J.E. P rin cip les and practice of infectious disease, ed 2. N ew York, John W iley and Sons, Inc, 1979, 1985, pp 585-591. 16. S a b isto n , C .B ., Jr.; G rigsb y, W .R .; and Segerstrom, N. Bacterial study of pyogenic infections of dental origin. Oral Surg Oral Med Oral Pathol 41(4):430-435, 1976. 17. Aldous, J.A.; Pow ell, G.L.; and Stenssas, S.S. Brain abscess of odontogenic origin: report of case. JADA 115(6):861-863, 1987.
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